Project Summary/ Abstract $25 billion is spent annually to care for patients with lower extremity ulcers due to peripheral artery disease (PAD) and Diabetes Mellitus (DM) in the United States. Despite this over 185,000 patients with PAD, DM, or combined PAD/DM undergo leg amputation with a risk of 55% for amputation of the opposite leg. In rural patients the risk is 50% higher compared to urban areas. Guidelines for treating lower extremity ulcers are founded on objective evaluation of arterial perfusion with ankle brachial index (ABI) testing and characterization of the ulcer using a validated classification system (WIfI). Barriers to implementation of both include poor dissemination among primary providers, questions of how to implement tools within a busy clinical practice, and limited access to subsequent treatment. Adoption of telemedicine to manage patients with lower extremity ulcers has been low; however, we believe that the use of telemedicine in addition to dissemination and implementation of evidence based guidelines can improve timing of care and may reduce hospitalizations, emergency room visits, and amputations. My long-term goal is to decrease preventable amputations for patients with foot ulcers due to DM and/or PAD. My immediate goal is to develop my skills as an implementation science researcher with a focus on bringing evidence based guidelines to rural clinics and providing specialty care using telemedicine, and evaluating the effect of patient activation influences outcomes. The K23 award will support my time to implement ABI and WIfI use in rural clinics and to use telemedicine to improve timing of care, which may ultimately decrease hospitalizations and amputations. There are several relevant and complementary resources available to me within the environment at UC Davis. First and foremost, the NIH Clinical & Translational Science Center (CTSC) represents a substantial resource pool including grant and statistical support as well as Informatics and database support. The UC Davis Center for Healthcare and Technology (CHT), where Dr. Marcin serves as the Director of Pediatric Telemedicine, has all the resources needed to conduct specialist consultation through telemedicine already in place. Finally, the UC Davis Center for Healthcare Policy and Research (CHPR), led by Joy Melnikow, has a robust network of qualitative researchers with experience in patient centered studies as well as health policy researchers to provide methods expertise and support implementation of the project. The UC Davis Surgical Outcomes Group, of which I am a member, holds monthly meetings to discuss ?research in progress?. This group will serve as a valuable tool for reviewing ideas and analytical work during my grant. Overall, without the collaborative nature at UC Davis, I would not be able to succeed in this proposal.